Definition of hand sweating disorder
Hand sweating disorder is a disease in which the sweat glands of the hands are hypersecreted. It is mainly characterized by excessive sweating of the palms of the hands, but may also be accompanied by excessive sweating of the axillae, soles of the feet, and head and face.
Epidemiology
According to statistics from Taiwan, China, an average of 3 out of 1000 young people have apparently severe palmar hyperhidrosis. In the United States, Srutton conducted a nationwide survey of 150,000 families in 2004, and the prevalence was 2.8%. A survey of 12,803 college and high school students in 20 colleges and universities in Fuzhou City identified 588 people with hand sweating, with a prevalence of 4.59%.
Pathogenesis
Numerous studies have shown that the histopathology of sweat glands in patients with hand sweating is not significantly abnormal, the sweat gland structure is not hypertrophic, and the number of sweat glands does not increase; therefore, the pathogenesis of hand sweating is not rooted in the sweat glands. Most scholars believe that hand sweating is a phenomenon of autonomic nervous system disorder. It is believed that the pathogenesis of hand sweating is hyperexcitability of the thoracic sympathetic ganglion. These include increased sympathetic control by the sympathetic nerve center, increased sympathetic self-conduction, and increased excitability of the thoracic sympathetic ganglion.
Daily manifestations of hand sweating disorder
Hand sweating is mainly characterized by excessive sweating on the palms, soles, and armpits. In mild cases, the palms are moist, and in severe cases, the palms may secrete beads of sweat visible to the naked eye. Patients with hand sweating often develop excessive sweating on the palms of their hands since childhood or adolescence, which affects their daily life and work. The sweaty hands tend to affect the dexterity of hand manipulation and interfere with manual operations. Patients avoid shaking hands with others, which affects interpersonal communication and creates avoidance and anxiety. Surveys show that 50% of patients feel a lack of self-confidence, 38% have a sense of frustration, and 20% have a sense of depression.
Grading and quantification of hand sweating symptoms
Lai Hand Sweating Symptom Grading Scale
Mild: moist palms
Moderate: Palm sweating soaked through a handkerchief
Severe: sweaty palms with dripping beads
Hyperhidrosis Quantitative Assessment Form
1.Please self-describe the severity of hyperhidrosis Light 1234567 Heavy
2.How much hyperhidrosis interferes with study, life and work Light 1234567 Heavy
3.The degree of skin discomfort caused by excessive sweating Light 1234567 Heavy
4.The number of times to change clothes due to excessive sweating (times/day) 123456>=7
5.The number of times I need to take a bath due to excessive sweating (times/day) 123456>=7
6.The number of times to use drying powder due to excessive sweating (times/day) 123456>=7
Diagnostic criteria of hand sweating disorder
In 2004, John Hornberger of the American Academy of Dermatology organized a collaborative group of experts to develop a diagnostic reference standard.
The diagnosis is confirmed by the presence of hyperhidrosis of the sweat glands for more than 6 months without an obvious cause and if two of the following conditions are met
The diagnosis is confirmed if hyperhidrosis of the sweat glands has been visible for more than 6 months without an obvious cause and if two of the following conditions are met
Bilateral symmetry of sweating areas
At least one episode per week
Age of onset less than 25 years
Positive family history
absence of sweating during sleep
Interferes with daily work life
Non-surgical treatment
I. Direct current and iontophoresis
Direct current therapy is the application of direct current at a steady voltage to the tissues to cause a series of biological effects that affect or destroy the secretory function of the sweat glands for therapeutic purposes.
During the treatment period, hand sweating is reduced significantly, but after a few weeks to months of stopping the treatment, excessive sweating symptoms will appear again, and repeated treatment can still be effective, but the overall efficacy is not good.
Second, drug treatment
1.Treatment with local topical drugs
Mostly use astringents and drugs that inhibit the secretion of small sweat glands. Such as: aluminum chloride, potassium alum, formaldehyde, urotropine.
2, oral drug therapy
Such as anticholinergics, anticonvulsants. Treatment is temporary and has obvious side effects, and is generally not recommended.
Non-surgical treatment
C. Botulinum toxin type A for hand sweating
Because the skin of the hand is more sensitive, there are many injection points, and the pain is obvious when Botox is injected. The effectiveness rate can reach 90%; however, most of them relapse within 4~6 months.
Minimally invasive surgical treatment
Thoracoscopic (or mediastinoscopic) sympathectomy (endoscopicthoracicsympathectomy, ETS) is performed by making small incisions of 1.5-2.5 cm on each side of the chest in the anterior axillary line, inserting a TV thoracoscope, and placing an electric hook suction through the mirror tube to determine the T2 and T3 (or T4) sympathetic ganglia and then electrocautery them with an electric hook.
I. Indications for surgery.
1, Age: 10~50 years old (15~40 years old is best)
2. Your sweaty hands significantly affect your interactions, schooling, work, mood and life, or significantly reduce your self-confidence.
Second, contraindications to surgery.
1, general surgical contraindications: allergic constitution, mental illness and dysfunction of important organs such as the heart, liver, lungs and brain.
2, patients with certain diseases: autoimmune vasculitis, thoracic outlet syndrome, pathological reaction of the fingers to cold.
3. Those who are not suitable for thoracoscopic surgery: patients who have suffered from abscess chest, pneumonia, tuberculosis resulting in pleural adhesions and pleural hypertrophy.
Third, the method: double-lumen tracheal intubation with general anesthesia, 30° to 45° semi-sitting position, both arms abducted 90°, the body temperature monitor was placed on the palm of the hand to compare the preoperative and postoperative palm temperature. For single-lumen bilateral ventilation, a small incision of 1.5-2.5 cm was made in the third intercostal space in the anterior axillary line, a TV mediastinoscope was inserted, and an electric hook suction was placed through the mirror tube to determine the T2 and T3 (or T4) sympathetic ganglia and then cut them off with electric hooks with a slightly wider range.
The TV mediastinoscope was withdrawn after removing the electric hook suction device and checking for no intra-thoracic hemorrhage, suturing the muscle layer of the anterior axillary line incision without tying the knot for the time being, inserting the suction device, instructing the anesthesiologist to inflate the lung and maintain positive airway pressure for a few seconds, tying the knot after withdrawing the suction device, and suturing the incision intradermally. The same method was used on the contralateral side.
If intraoperative one-lung ventilation is unsatisfactory, respiratory suspension for 2-3 min can be used to make the lung rapidly atrophy, clearly reveal the sympathetic chain and cut off, and this method was used in this group. During the operation, strict observation of the change of oxygen saturation is required. If the oxygen saturation is ≤80%, the operation should be suspended and ventilation should be resumed until the oxygen saturation is normal, and then the operation should be continued. Routine chest X-ray is performed on the first day after surgery to exclude hemopneumothorax or pulmonary insufficiency.
Fourth, the superiority of TV thoracoscopic thoracic sympathetic nerve chain dissection: open thoracic sympathetic nerve chain dissection has been used in clinical practice since 1920, but it is difficult for patients to accept because of the large trauma, many complications, and the impact on function and aesthetics. TV thoracoscopic thoracic sympathectomy has the advantages of small trauma, easy operation, short operation time, precise efficacy and short hospital stay, but 2-3 small incisions of 0.5-1.0 cm are needed on each side of the chest.
The end of the TV thoracoscope is connected with fiber optic cable and camera, and can be directly connected to the monitor and camera of the TV thoracoscope, and it can also be connected to the computer and color printer to complete the preservation of the surgical data at any time.
Fifth, the range of thoracic sympathetic nerve chain cut: the range of thoracic sympathetic nerve chain excision varies from report to report. The sympathetic nerves that innervate the sweat glands of the face and upper extremities emanate from the T2 sympathetic ganglion, but a few reach the upper extremities directly through the KUNTZ bundle from T2 and T3, while the sympathetic nerves that innervate the eyelids and pupils emanate from the T1 sympathetic ganglion, and the axillae are innervated by T4 and T5.
Therefore, it has been suggested that cutting only T2 and T3 sympathetic ganglia in simple hand sweating can treat excessive sweating of the face and hands and avoid eyelid ptosis and pupil narrowing, while T4 and T5 ganglia should be cut simultaneously if combined with axillary sweating. We routinely cut the sympathetic nerve chain from T2 to T3, expanding to T4 in cases of combined axillary hyperhidrosis.
The nerve has been cut by laser, phenol cautery, scissor cutting, electrocautery, and electrocoagulation. It has also been suggested that the same effect can be achieved by ligation or titanium clamping of the T2 sympathetic nerve trunk alone without excision or cautery to destroy the sympathetic nerve. We have learned that electrocautery of the thoracic sympathetic nerve chain with an electric hook through a television mediastinoscope is simple, quick, and effective.
The complications of the operation are mild and few, mainly pneumothorax, subcutaneous emphysema, intercostal neuralgia, compensatory trunk and lower limb sweating, etc.
A. Pneumothorax, subcutaneous emphysema: There are many ways to prevent pneumothorax, some people routinely place closed drainage after surgery, some people put catheters in the incision to vent, parallel negative pressure suction, and remove the lungs after expansion. Others insert a rubber tube into the chest cavity and place the distal end into a small bowl containing saline to form a set of underwater containment devices to remove gas from the chest cavity.
After we complete the sympathetic chain cut, the suction is inserted, the anesthesiologist inflates the lung and maintains positive airway pressure for a few seconds, and the knot is tied after the suction is withdrawn.
Second, hemorrhage: common larger branches are close to the nerve chain before entering the odd vein, and there are intercostal veins, arteries and intercostal nerves between the ribs, which are prone to hemorrhage and intercostal neuralgia if injured. We use segmental severing of T2 and T3 nerve chain, which can avoid injury to intercostal vessels and nerves, and electrocautery with electrocoagulation attractor for the residual part of sympathetic nerve from T2 to T4.
In case of transverse small vessels, first electrocoagulation or titanium clamps on both sides of the sympathetic nerve chain and then branding, when severing the traffic branch as close to the ganglion as possible, small bleeding can be stopped by electrocoagulation with an electrocoagulation attractor, if still unable to stop bleeding, titanium clamps can be used.
Compensatory hyperhidrosis: Compensatory hyperhidrosis is the most common complication after sympathectomy in patients with hand sweating, with an incidence of 30%-75% reported in the literature, and the mechanism is not known. In addition, patients with hyperhidrosis are particularly prone to compensatory hyperhidrosis after surgery.
HSU et al. suggested that excision of only the T2 sympathetic ganglion and its adjacent nerve chain could effectively cure hand sweating, reduce excessive sweating in the face and axillae, and also reduce compensatory hyperhidrosis in the trunk. Hu et al. advocated that cutting only the T2 and T4 sympathetic ganglia could reduce its occurrence. We routinely cut the T2 to T3 sympathetic chain, and if combined with axillary hyperhidrosis, the T4 sympathetic chain is cut.
In addition, complications of Horner’s syndrome have been reported in the literature. We believe that the stellate ganglion is above the top of the thoracic cavity, and as long as the nerve above the 2nd segment is not deliberately electrocauterized, the complication of Horner’s syndrome can be avoided, and none of the cases in our group had Horner’s syndrome.
In conclusion, TV thoracoscopic thoracic sympathetic nerve chain dissection for hand sweating can achieve the exposure and therapeutic effect of TV thoracoscopy, and it is more minimally invasive, convenient and simple with only 1 incision, which is easily accepted by patients and can partially replace TV thoracoscopic technique.